[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
IS THERE A DOCTOR IN THE MOUSE? USING INFORMATION TECHNOLOGY TO IMPROVE
HEALTH CARE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON THE FEDERAL WORKFORCE
AND AGENCY ORGANIZATION
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
JULY 27, 2005
__________
Serial No. 109-127
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
http://www.house.gov/reform
_____
U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON: 2006
26-656 PDF
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
CHRISTOPHER SHAYS, Connecticut HENRY A. WAXMAN, California
DAN BURTON, Indiana TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
GIL GUTKNECHT, Minnesota CAROLYN B. MALONEY, New York
MARK E. SOUDER, Indiana ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio DENNIS J. KUCINICH, Ohio
TODD RUSSELL PLATTS, Pennsylvania DANNY K. DAVIS, Illinois
CHRIS CANNON, Utah WM. LACY CLAY, Missouri
JOHN J. DUNCAN, Jr., Tennessee DIANE E. WATSON, California
CANDICE S. MILLER, Michigan STEPHEN F. LYNCH, Massachusetts
MICHAEL R. TURNER, Ohio CHRIS VAN HOLLEN, Maryland
DARRELL E. ISSA, California LINDA T. SANCHEZ, California
GINNY BROWN-WAITE, Florida C.A. DUTCH RUPPERSBERGER, Maryland
JON C. PORTER, Nevada BRIAN HIGGINS, New York
KENNY MARCHANT, Texas ELEANOR HOLMES NORTON, District of
LYNN A. WESTMORELAND, Georgia Columbia
PATRICK T. McHENRY, North Carolina ------
CHARLES W. DENT, Pennsylvania BERNARD SANDERS, Vermont
VIRGINIA FOXX, North Carolina (Independent)
------ ------
Melissa Wojciak, Staff Director
David Marin, Deputy Staff Director/Communications Director
Rob Borden, Parliamentarian
Teresa Austin, Chief Clerk
Phil Barnett, Minority Chief of Staff/Chief Counsel
Subcommittee on the Federal Workforce and Agency Organization
JON C. PORTER, Nevada, Chairman
JOHN L. MICA, Florida DANNY K. DAVIS, Illinois
TOM DAVIS, Virginia MAJOR R. OWENS, New York
DARRELL E. ISSA, California ELEANOR HOLMES NORTON, District of
KENNY MARCHANT, Texas Columbia
PATRICK T. McHENRY, North Carolina ELIJAH E. CUMMINGS, Maryland
JEAN SCHMIDT, Ohio CHRIS VAN HOLLEN, Maryland
Ex Officio
HENRY A. WAXMAN, California
Ron Martinson, Staff Director
Chad Bungard, Deputy Staff Director
Chad Christofferson, Clerk
Tania Shand, Minority Professional Staff Member
C O N T E N T S
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Page
Hearing held on July 27, 2005.................................... 1
Statement of:
Brailer, David, M.D., Ph.D., National Health Information
Technology Coordinator, Department of Health and Human
Services; and Carolyn M. Clancy, M.D., Director for the
Agency for Health Care Research and Quality, Department of
Health and Human Services.................................. 30
Brailer, David........................................... 30
Clancy, Carolyn M........................................ 45
Fineburg, Harvey, M.D., Ph.D., president, Institute of
Medicine; David St. Clair, founder and CEO, MEDecision,
Inc.; and Jan Walker, RN, MBA, executive director, Center
for Information Technology Leadership [CITL]............... 65
Fineburg, Harvey......................................... 65
St. Clair, David......................................... 75
Walker, Jan.............................................. 81
Kennedy, Hon. Patrick, a Representative in Congress from the
State of Rhode Island...................................... 8
Springer, Linda M., Director, Office of Personnel Management. 23
Letters, statements, etc., submitted for the record by:
Brailer, David, M.D., Ph.D., National Health Information
Technology Coordinator, Department of Health and Human
Services, prepared statement of............................ 33
Clancy, Carolyn M., M.D., Director for the Agency for Health
Care Research and Quality, Department of Health and Human
Services, prepared statement of............................ 48
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland, prepared statement of............... 91
Davis, Hon. Danny K., a Representative in Congress from the
State of Illinois, prepared statement of................... 22
Fineburg, Harvey, M.D., Ph.D., president, Institute of
Medicine, prepared statement of............................ 67
Kennedy, Hon. Patrick, a Representative in Congress from the
State of Rhode Island, prepared statement of............... 9
Murphy, Hon. Tim, a Representative in Congress from the State
of Pennsylvania, prepared statement of..................... 13
Porter, Hon. Jon C., a Representative in Congress from the
State of Nevada, prepared statement of..................... 5
Springer, Linda M., Director, Office of Personnel Management,
prepared statement of...................................... 26
St. Clair, David, founder and CEO, MEDecision, Inc., prepared
statement of............................................... 77
Walker, Jan, RN, MBA, executive director, Center for
Information Technology Leadership [CITL], prepared
statement of............................................... 83
IS THERE A DOCTOR IN THE MOUSE? USING INFORMATION TECHNOLOGY TO IMPROVE
HEALTH CARE
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WEDNESDAY, JULY 27, 2005
House of Representatives,
Subcommittee on Federal Workforce and Agency
Organization,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:02 p.m. in
room 2154, Rayburn House Office Building, Hon. John C. Porter
(chairman of the subcommittee) presiding.
Present: Representatives Porter, Davis of Illinois, and
Norton.
Staff present: Chad Bungard, assistant staff director,
chief counsel; Ronald Martinson, staff director; Chad
Christofferson, clerk; Patrick Jennings, detailee from OPM
serving as senior counsel; and Tania Shand, minority
professional staff member.
Mr. Porter. A quorum being present, the Subcommittee on the
Federal Workforce and Agency Organization will come to order.
Good afternoon. I would like to thank everyone for being
here today, especially our witnesses. The issue before us is an
important one and something to which we can all relate. Every
single one of us has gone to the doctor's office or the
hospital or knows someone that has made such visits.
With both legislative jurisdiction over the Federal
Employees Health Benefits [FEHB], program and oversight
jurisdiction over health care policy, this subcommittee is
poised to examine ways to achieve President Bush's goal for the
majority of Americans to have electronic health records within
10 years.
Notwithstanding the fact that the United States is a world
leader in health care science, its delivery and management of
health care is often outmoded and inefficient. Over 90 percent
of the activities that go into the delivery of health care are
centered on information and information exchange. If this
component is flawed in any way, the optimal delivery of care
will not be achieved.
Health care costs are increasing at an alarming rate,
rising 70 percent since 2000. The quality of care is riddled
with preventable medical and administrative errors and burdened
with inefficiency.
Information technology can help cure these ills. With the
deployment of health information technology in a global
fashion, no longer will patients have to be held captive to the
brown padded envelopes in the bottom of their chest of drawers
full of incomplete medical records. No longer will patients
have to track down personal health information from across the
country.
No longer will a pharmacist misread a doctor's handwriting
and prescribe the wrong medicine. No longer will medical errors
occur caused by the lack of or incomplete health information.
And, as Dr. David Brailer noted at a technology summit last
year, ``no longer will we spend up to $300 billion a year on
inappropriate treatment or up to $150 billion on administrative
waste.''
The use of information technology has enormous potential to
improve the quality of health care and is key to overall
improved performance of the U.S. health system. Health care
organizations are only beginning to apply technological
advances. Patient information typically is dispersed in a
collection of paper records, which often are poorly organized,
illegible, and not easy to retrieve, making it nearly
impossible to manage various chronic illnesses that require
frequent monitoring and ongoing patient support.
In a world where our cars, our pets, our checking accounts
have their own computerized record, is not it time for every
American to benefit from the same technology? And I must
emphasize the benefits are innumerable. The Institute of
Medicine estimates that medical errors account for
approximately 45,000 to 98,000 deaths each year in the United
States, and 770,000 injuries due to adverse drug events, many
of which could have been prevented through the use of health
information technology.
In fact, more people die each year in the United States
from medical errors than from highway accidents, breast cancer,
or even AIDS. If death by medical errors were listed among the
most deadly diseases, it would be among the top 10 leading
causes of death in the United States each year.
The use of technology will reduce medical errors by making
health information more accessible to both patients and
providers, no matter where the patient is receiving that care.
For example, the Boston Globe recently reported on the
senseless, preventable death of a 79 year old retired chemist
who died after doctors at the Massachusetts General Hospital
treated him for a stroke when he really was having an insulin
reaction. Tragic. It is easy to see how an electronic medical
record could have assisted the physicians in correctly
diagnosing this patient.
In addition, the use of automated medication order entry
systems can reduce errors in prescribing drugs, and
computerized reminders can help both patients and clinicians to
identify needed services. The Journal of the American Medical
Association reported in a recent study that computerized
prescriptions resulted in an 81 percent decrease in errors. The
National Center for Vital and Health Statistics reports that 20
percent of handwritten medical documents are illegible, and 24
percent are incomplete. Prescription errors can result in real
catastrophes that easily could be prevented.
Recently, a 42-year-old male patient died 2 weeks after
taking the wrong prescription drug. In that case the doctor who
wrote the prescription wrote it for the wrong amount. It was
actually eight times higher than what he should have been
receiving.
The Department of Health and Human Services also reports
that health information technology can significantly reduce
cost by saving time, reducing duplication and waste, and
improving efficiency. The Center for Information Technology
Leadership estimates that a national health information
technology system will result in annual savings of $132
billion. With national health care spending at a 15.6 percent
share of the GDP, this is welcome news.
The benefits of computerizing health records are
substantial. Health information technology will improve the
quality of care, reduce the redundancy of testing and
paperwork, virtually eliminating prescription errors, prevent
adverse effects from conflicting courses of treatment, and
significantly reduce medical errors and administrative costs.
In announcing his 10 year goal, the President admonished
the Federal Government to take the lead. The FEHB program is no
exception and should leverage its buying power of about 8\1/2\
million participants to support President Bush's goal and lead
by example.
As the Institute of Medicine's president, Dr. Harvey
Fineburg, stressed in testimony before this subcommittee this
past March, the FEHB program could promote data standards and
appropriate deployment of information technology providers. And
since that hearing I am pleased to see that the Office of
Personnel Management emphasized the importance of increase of
health information technology for the first time in its April
2005, program carrier letter, offering guidance to insurance
carriers for negotiating with the OPM.
The FEHB program can enhance its service to Federal
employees and serve as a model for improving the performance of
U.S. health care systems as a whole.
Progress is also being made on the national front. In June
of this year HHS Secretary Mike Leavitt announced new efforts
to help speed the President's 10-year proposal, stating that
the HHS will establish a national health information
infrastructure that will effectively be taken over by the
public and private health sectors, eventually eliminating the
need for extensive Federal involvement.
No one can claim that moving information technology into
the health care industry is going to be easy. There are many
challenges of implementing information technology, including
financial, technical, cultural, turf. These are but a few of
the challenges that we have.
As chairman of this subcommittee, I am committed to
supporting the President's goal and guiding the implementation
of health information technology in both the FEHB program and
throughout the Nation. This subcommittee will hold additional
hearings over the next several months to face the challenges
head on and achieve meaningful improvement in America's health
care system.
The individuals before the subcommittee today are vital
players and leaders in achieving our goal and the President's
goal, and I look forward to discussion from all the witnesses
this afternoon.
I have had the opportunity to spend time in Nevada
hospitals. I have had a chance to see first-hand. And yes, I
have been sick in the hospitals before, but I have been very
specific in spending time in the emergency rooms to see what I
could do as a Member of Congress. University Medical Center, a
major facility in southern Nevada, I have spent a couple of
days just working hand in hand with the doctors--of course,
staying out of the way--trying to see what we could do. I am
amazed at how well our delivery system does work, even in spite
of some of the technological challenges. But I saw first-hand
how technology could be such a lifesaver in many respects
around the country, not only in Nevada but in every community
across this great country.
Having said that, I would like to now recognize our ranking
minority member of the subcommittee, Mr. Danny Davis. Mr.
Davis.
[The prepared statement of Hon. Jon C. Porter follows:]
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Mr. Davis of Illinois. Mr. Chairman, I do not know what
Representative Kennedy's time piece is, but if he would have a
problem returning after the votes then I would defer to him and
let him give his testimony. If not, then I will go ahead.
Mr. Kennedy. No problem. That would be appreciated. If you
are having another hearing down the road, I would be willing to
testify at that, as well. If you want me to make brief comments
now, I would be happy to come back at the next hearing.
Mr. Porter. Without objection.
Mr. Davis of Illinois. I am prepared to yield to the
Representative.
Mr. Porter. Thank you. Without objection, please. Welcome.
STATEMENT OF HON. PATRICK KENNEDY, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF RHODE ISLAND
Mr. Kennedy. Thank you. Thanks, Mr. Chairman,
Representative Davis.
Mr. Chairman, you just outlined essentially the problem and
possibly the direction for us to go in terms of the solution.
But I think what is important here is that this is not a
hearing about technology. This is a hearing about saving lives.
You hit it on the head at the outset, Mr. Chairman, when
you said that roughly 48,000 to 100,000 people in this country
die of medical errors. It is the equivalent of a jumbo jet
crashing every 3 days in this country. If the American people
really understood the degree to which they are in jeopardy of
being a victim of a medical error when they go to the hospital,
Mr. Chairman, I know this Capitol would be awash with people
from all over the country demanding that we would do something.
Mr. Chairman, I think people are learning about this and
they are expecting us to begin to reform this system.
Technology can be a big part of that. Mr. Chairman,
Representative Murphy and myself have offered a piece of
legislation that suggests a way to go about implementing IT in
our medical system in this country. Everybody has recognized
the need to do this, but now we have to actually do it, Mr.
Chairman. That I think is our challenge here.
As you all are able to do this through showing how
Government can be a model for the rest of the country, I think
it is an important role that you will play in this debate,
because the Federal Employees Health Benefits program is going
to be a program that will be looked to as a model. And so I
encourage you to continue to talk about how you are intending
to do that. I look forward to coming back when you have
successive hearings to be able to comment further about ways
that you might do that.
I thank you for holding this hearing and focusing the
attention that you are focusing on this very important subject.
[The prepared statements of Hon. Patrick Kennedy And Hon.
Tim Murphy follow:]
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Mr. Porter. Thank you, Congressman. We appreciate your
leadership in a bipartisan nature with Congressman Murphy, who
is sick today.
Mr. Kennedy. That is right.
Mr. Porter. Here we are talking about health care, and my
friend Tim decides to be ill. But certainly we appreciate what
you are doing and we look forward to working with you and
applaud you for your leadership. Thank you very much.
Mr. Kennedy. Thank you very much, Mr. Chairman.
Mr. Porter. We will now go into recess until our votes are
concluded.
Thank you.
[Recess.]
Mr. Porter. I would like to bring the meeting back to
order.
For those that have attended a few of our subcommittee
hearings in the past, I have been promising to hold our
hearings in Las Vegas. Well, I think I am not sure whether it
is cooler here or in Las Vegas today. We will be having a
hearing in Las Vegas some time in August, so you are welcome to
join us around the 12th. If you are looking for a reason to
come to Nevada, we are going to be having a hearing in the dry,
wonderful southwest.
Thank you for your patience. We will bring the meeting back
to order.
I would like to turn to Mr. Davis for any opening comments.
Mr. Davis of Illinois. Thank you very kindly, Mr. Chairman.
Let me thank you for calling this hearing. This is a very
timely subject for the subcommittee to be considering.
The utilization of information technology to improve the
Nation's health care system has gained a great deal of momentum
since the Institute of Medicine released its 1996 report on
health IT: ``To Err Is Human: Building a Safer Health System.''
As a matter of fact, health IT is featured in the August 1,
2005, issue of Health and Medicine section of U.S. News and
World Report. One of the articles in the magazine, ``Can High
Tech Save Your Life?,'' listed 47 hospitals that earn two
impressive distinctions: first, the hospitals were listed among
America's best hospitals, U.S. News and World Report's ranking
of hospitals that is based on expertise, ability to save lives,
reputation among specialists, commitment to nursing excellence,
and several other factors.
Those hospitals also made the 100 Most Wired List compiled
by hospitals and health networks and published by the American
Hospital Association. It is a list that identifies the
hospitals and health systems that have the most complete
information technology. It would appear that those hospitals
have successfully used health IT, the technology used to
collect, store, retrieve, and transfer health information
electronically to improve the quality and safety of health care
for their patients.
When compared to other institutions, the mortality rate of
the 100 Most Wired Hospitals was 7.2 percent lower on average.
While there seemed to be a connection between improved patient
outcomes and health IT, matters of patient privacy, continued
human care, and the accessibility of online medical data should
be addressed by health care providers as they adopt IT policies
and systems.
I might just add, Mr. Chairman, that you really appreciate
our looking into this matter. I have had a long and intimate
association with health care, representing more hospital beds
than any other Member of Congress in the United States, having
many of the finest hospitals in the country and medical schools
in my Congressional District. As a matter of fact, there are
four of them--Northwestern University, University of Illinois
at Chicago, Rush Presbyterian, St. Luke's Medical Center,
Loyola University--as well as a number of smaller community
hospitals threaded throughout the area.
I have also spent a great deal of my personal career
involved in health care. As a matter of fact, I have sat on the
boards of hospitals, I have worked in community health centers,
I have been an active member of the American Public Health
Association. As a matter of fact, I wrote my doctoral
dissertation on the health care needs of black Chicago. I have
worked with doctors and hospitals and been on a couple of
Federal commissions that I was appointed to, one by President
Carter and some other people. So health has been pretty much my
life, and the most exciting part of my life.
So as we try and find ways to improve the quality of care
and find new ways to protect our public, it is exciting and
challenging, and so I certainly thank you for delving into this
arena and look forward to the testimony of our witnesses.
I yield back.
Mr. Porter. Thank you, Mr. Davis.
Mr. Davis of Illinois. And the medical center that you are
talking about out in Vegas, my good friend is the director, a
fellow named Lacy Thomas, who used to work for me.
Mr. Porter. You trained him very well. He is doing a great
job.
Mr. Davis of Illinois. I am glad to know that he is doing
well.
Mr. Porter. He is doing real well. So maybe when you are
out for the meeting in August we can stop and see him.
Mr. Davis of Illinois. Absolutely.
[The prepared statement of Hon. Danny K. Davis follows:]
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Mr. Porter. With that, I ask unanimous consent that all
Members have 5 legislative days to submit written statements
and questions for the record, and the answers to written
questions provided by the witnesses also be included in the
record.
Without objection, so ordered.
I ask unanimous consent that all exhibits, documents, other
materials referred to by Members and witnesses may be included
in the hearing record and that all Members be permitted to
revise and extend their remarks.
Without objection, so ordered.
It is also the practice of this subcommittee to administer
the oath to all witnesses. If all witnesses would please stand,
I would like to administer the oath.
[Witnesses sworn.]
Mr. Porter. Let the record show that the witnesses have
answered in the affirmative.
We have four panels today. As you know, we started with
one, which was very brief for politicians. We appreciate
Congressman Kennedy for his leadership and we certainly will
have him a part of our additional hearings and will also have
Congressman Murphy joining us.
So what I would like to do now is move into our second
panel. Our second panel, we will hear from Linda Springer, the
Director for Office of Personnel Management. In fairness, Ms.
Springer and I have met numerous times over the past month or
so, but we note that this is her first hearing with our
committee. We are honored to have her.
I know that in the brief amount of time that you have had
on the job you have been getting a lot of things together, and
I know that even prior to being in a new position you were
aware of a lot of these issues. We welcome you and understand
that, in your long term of serving the business community and
the public sector, you have had a very distinguished career,
and we appreciate your being here today.
You have 5 minutes. We look forward to having you come
back.
STATEMENT OF LINDA M. SPRINGER, DIRECTOR, OFFICE OF PERSONNEL
MANAGEMENT
Ms. Springer. Thank you, Mr. Chairman. It is a privilege to
be here with this committee today with you and Representative
Davis on what we consider at OPM to be a very important issue,
and that is the efforts of OPM particularly in helping the
community to adopt the provisions of the health information
technology, particularly in the FEHB program.
I want to provide a little context for my remarks about
that adoption and in the way of background of the FEHB program
and OPM's role as the administrator.
There are approximately 8 million Federal employees,
retirees, and dependents who are covered by that program. The
program allows OPM to offer competitive health benefits for
Federal workers in a similar fashion that large employers are
able to procure that in the private sector.
We administer the program by contracting directly with
private sector providers, but not with the doctors, themselves,
so we do not have specific oversight there, but indirectly we
do through the health programs.
Now, with that background I would like to talk a little bit
about the direct subject of this hearing and our related
activities with the FEHB program.
Under the Executive order issued by President Bush related
to the health information technology, there were several areas
where OPM was directed to provide information and to work
closely to promote its enactment. The order underscored really
the importance that the President places on the development of
this type of capability nationwide and to have health
information technology infrastructures in place that will
improve quality, safety, and efficiency of health care.
In order to help fulfill the President's vision, OPM,
working also with the Veterans Affairs Department and also
Department of Defense, was directed to submit a report within
90 days of the Executive order on various options and
incentives that we could put into place in the FEHB program to
try and promote adoption of these health information technology
opportunities.
In July 2004 OPM fulfilled that requirement and issued a
report to the President outlining various options to provide
incentives in the FEHB program. Among those options were the
following: Encouraging health plans to provide incentives for
the adoption of interoperable health information technology
systems under the FEHB contracts. Consider basing part of the
service charge or profit for the fee for service plans and
other experience rated plans and consider introducing
performance goals for health maintenance organizations--this is
where you really are putting your money where your mouth is
when you start talking about their service fees. Introducing
incentives and other performance goals for plans that contract
with networks of providers to make records accessible through
secure--and I want to underscore secure--and other HIPPA
compliant interoperable HIT systems. Introducing incentives and
performance goals for plans that integrate their provider
networks with local and national health information
infrastructure initiatives. Also encouraging and rewarding
carriers that contract with pharmacy benefit managers that are
providing incentives for e-prescribing and health information
technology linkages.
Earlier this year OPM staff met with Dr. Brailer, HHS'
national health information technology coordinator, and his
staff on how we could work closely with them to help promote
and to move forward the agenda that they have. In April 2005,
Dr. Brailer was the keynote speaker at our annual FEHB carrier
conference. His staff also had a followup workshop at the
conference to provide more in-depth information for the plans
that are participating in the FEHB program. Again, the idea
there was to have direct contact without any intermediary for
the members of the FEHB program and Dr. Brailer.
Following this conference, OPM issued the annual Call
Letter to the carriers that are in the FEHB. This carrier
letter provides guidance and negotiation objectives for benefit
and rate proposals for the FEHB program for the next contract
term. I have a copy of that Call Letter here, but if you look
at the Letter you will find that about a page, a solid page of
this is in the Letter this year that would not have been here
in the past were it not for the new initiatives on HIT. So
clearly OPM is taking some very concrete actions with respect
to our carriers.
The Call Letter requested that plans describe their HIT
initiatives, including any currently in place for the doctors
and pharmacies to use e-prescribing and for contracting
hospitals to use electronic registries, electronic records, and
e-prescribing. We have received responses from the FEHB plans,
and we are in the process of reviewing them right now to
establish a baseline from which we can measure progress on how
they are doing.
OPM's Web site is another important vehicle for
communicating with all of the members of the FEHB program. On
that Web site page for participating plans there are links to
HIT-related information such as regional health organizations,
and the focus on HHS' HIT initiatives and technology groups.
OPM has affiliated itself with a variety of other
organizations so that we can stay current on the efforts that
are undertaken to again develop this technology capability. We
are members of the e-health initiative, Employer and Purchaser
Advisory Board, and we are on other various public/private
partnership organizations that are focused on quality assurance
and quality forums that are focused on patient safety, health
care quality, and privacy issues.
With regard to current privacy protections, FEHB enrollees
have the same privacy protections as all Americans do in their
private plans. All program contracts require health plans to be
in complete compliance with HIPPA requirements, and as new
interoperable systems are developed OPM will ensure that FEHB
plans comply with any Federal requirements with respect to
privacy of health information.
We look forward to continuing to work with HHS and with our
FEHB participating health plans on our initiatives. We are
strongly committed to working forward alongside of the industry
and private partners in accomplishing this important objective.
This concludes my testimony, but I appreciate the
opportunity to answer any questions that you may have, Mr.
Chairman.
Mr. Porter. Thank you very much.
[The prepared statement of Ms. Springer follows:]
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Mr. Porter. I am going to forego my questions at this time
because the element of time is limited. I know we communicate
frequently, so I will save my questions.
Mr. Davis, do you have any questions?
Mr. Davis of Illinois. I only have one question.
How do you see patient privacy being handled with the
development of the centralized data base?
Ms. Springer. I think that patient privacy, first of all,
is really the key to acceptance of this type of thing. If we
could have all the technology in the world and all the
information in the world, but if the privacy is not there we
are really wasting our time because it will not be usable.
People will not accept it. All of these things require, as I
understand it, permission from the patient. They are optional.
They are not a mandatory type of thing.
So we have to show that the privacy safeguards are in
place, similar to any other type of thing where personal,
private information is used electronically. I think, as the
chairman mentioned in his opening statement, there are any
number of capabilities that are in place today where
information is available. Health care is one of the last
frontiers, if you will.
So we have to look to those areas to find out what they are
doing to ensure privacy and to make sure that it is there,
whether it is technologically or the kind of oversight
certification possibly that might be required. But I think it
is clear that without the privacy protections these efforts
will not be successful.
Mr. Davis of Illinois. Thank you.
Mr. Porter. Thank you. Thank you, Ms. Springer. We
appreciate it and look forward to working with you.
Ms. Springer. Thank you.
Mr. Porter. On panel three we have Dr. David Brailer, our
newly appointed National Health Information Technology
Coordinator at HHS; Dr. Carolyn Clancy, the Director for the
Agency for Health Care Research and Quality, also a division of
HHS. Thank you very much for being here.
It is going to help the subcommittee as well as Congress as
we move forward. You each will have 5 minutes. We start with
Dr. Brailer.
STATEMENTS OF DAVID BRAILER, M.D., PH.D., NATIONAL HEALTH
INFORMATION TECHNOLOGY COORDINATOR, DEPARTMENT OF HEALTH AND
HUMAN SERVICES; AND CAROLYN M. CLANCY, M.D., DIRECTOR FOR THE
AGENCY FOR HEALTH CARE RESEARCH AND QUALITY, DEPARTMENT OF
HEALTH AND HUMAN SERVICES
STATEMENT OF DAVID BRAILER
Dr. Brailer. Thank you, Chairman Porter and Ranking Member
Davis.
I have submitted my testimony in advance, and with your
consent I will just give brief remarks and then answer any of
your questions.
Efforts are well underway to advance health information
technology. There are numerous initiatives across the United
States in the Administration, which I will detail today, in
many States driven by Governors and legislatures, in local and
regional grassroots projects, and in the private sector. We
certainly welcome the interest of health IT in this
subcommittee and elsewhere in Congress.
We have set the foundation for health information
technology that is long-term, market-based, non-regulatory, and
with a primary focus on attributes that America's consumers
need: safety and quality, cost effectiveness, consumer
management, and threat preparedness.
Briefly, the foundations of our efforts fall into three
categories. First, clinically, we want to ensure that
clinicians have access to the kinds of information they need to
prevent errors and deaths, to make evidence-based treatment
decisions, and to reduce redundant treatments and unnecessary
treatments.
We want to bring disparate clinicians together because of
the overwhelming evidence that team-based care and
collaborative care improve patient's health status. We want to
get information to consumers so they can make their own
treatment decisions, be involved in critical management of
their own health, and choose providers who suit their own
needs.
There is a business foundation, as well, that arises from
strong support in the private sector for the use of health
information technology to improve the competitiveness of our
industry, to improve health status of employees, and to bring
productivity to the U.S. health care industry that is not
unlike productivity improvements we have seen in other sectors
of the economy, and, as an added benefit, to develop high-
technology jobs in the health care industry across our
providers in the United States.
The Federal Government has been called upon by private
sector leaders to be a catalyst and convener of this change--
and our actions reflect this orientation--and ultimately to use
our purchasing power to drive results. To that end, we have had
a very collaborative and positive relationship with OPM to be
able to accomplish that goal.
The technology foundations have been set by a recent RFI
that we have published which asks how do we accomplish the
goals of the Administration. Some of the key findings were: it
should be collaborative, with public and private players
involved; information should ultimately be patient centric,
about the patient, not about the doctor or the hospital; there
should be very strong privacy safeguards; the information
should be decentralized and regionally governed; and there
should be a nationwide communication, architecture, and
standards.
There are two fundamental aspects of our strategy. One is
interoperability and the other is electronic health record
adoption.
Interoperability is ultimately about getting information
where it is needed and when it is needed. Most of the clinical
value that we discuss is tied up in the ability to get
information to clinicians when they need it and have it be
full, complete, and accurate; yet, today there is very little
sharing of information and most of it that is done is patchy
and proprietary. There is very little portability of health
information toward consumers, and we cannot empower them
without getting their information together in a useful way.
The other component of our strategy is about electronic
health record adoption, and later the adoption of other health
information technology. There is a large gap in adoption
between large health care systems, large hospitals large
physician offices, and small ones. Large providers have the
know-how and resources to buy, develop, invest, implement, and
use advanced health information technology, and they are
driving most of the reported adoption. Smaller providers, small
physician offices, small hospitals have substantial barriers to
the adoption and use of health information technology. They are
lagging behind.
We are placing our primary efforts on ensuring that health
information is interoperable so that it can be seamlessly
following the patient. We are doing this because many
scientists and clinicians view that this is a key component of
the health care of the future, and it is something that we
believe has very strong support from the nearly unanimous
recommendations from the respondents to our RFI.
There are several other reasons for this approach, however.
It is a one-time chance. Before there is large-scale adoption
of electronic health records in the United States, we have a
chance today to put in the foundations for information sharing
so we can overcome fragmentation of health care. We can enable
portable health information and personal health records for our
consumers, we can stimulate electronic health record adoption
without subsidies, because interoperability lowers the cost and
increases the benefits of electronic health records.
We can increase the industry's capacity to implement these
tools by eliminating the labor-intensive and risky components
of implementation to make products more plug and play. And we
can promote innovation and fundamental research by developing
new areas where technology can have promise for our clinicians.
We have allocated $86\1/2\ million to achieve these goals
in fiscal year 2005, and we have requested $125 million to
advance this work further in 2006.
I appreciate your interest in the topic and I look forward
to further discussion and answering your questions. Thank you.
Mr. Porter. Thank you, Doctor. We appreciate it.
[The prepared statement of Dr. Brailer follows:]
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Mr. Porter. Dr. Clancy, please.
STATEMENT OF CAROLYN M. CLANCY
Dr. Clancy. Good afternoon, Mr. Chairman. I am delighted to
outline the ways in which the Agency for Health Care Research
and Quality [AHRQ], is advancing the adoption, implementation,
and effective use of health information technology.
I have asked that my written testimony be submitted for the
record.
AHRQ's research portfolio will help the Nation meet three
vital objectives: reducing medical errors, improving the
quality of patient care, and reducing the cost of health care.
For nearly three decades AHRQ has funded the basic science of
health IT by supporting the pioneers and innovators so that
many of the Nation's leading health IT systems have actually
been established from AHRQ-supported research. Our task now is
to spread the knowledge and experience that we have gained more
broadly throughout the health care system, and we also need to
support research targeted to address some critical gaps.
In fiscal year 2004, AHRQ announced an investment of $139
million over 5 years to achieve these goals. This national
initiative is now supporting 108 grants and contracts in 43
States with over half of the projects based in rural and small
hospitals and clinics. All told, this investment will affect
more than 40 million Americans. My written statement details
extensively these projects, but I would like to provide some
highlights now.
First, I would like to note briefly the important role that
consumers can play in improving health care. Informed and
engaged consumers who work in partnership with clinicians I
think are an untapped resource. We need to make sure that they
have the tools they need to make choices using evidence-based
information. We have made it a priority to develop evidence-
based information for consumers and are very pleased that our
partner, OPM, is the leading edge of making this information
available for its customers.
Mr. Chairman, as a Federal employee you can go to the FEHB
Web site and use an AHRQ-developed tool called CAPS, which
stands for the consumer assessment of health plan survey, to
help you choose your plan.
So we are now looking to the power of health IT to
customize evidence and information about treatment choices,
diagnostic options, and to put that into the hands of consumers
and providers.
Under the Medicare Modernization Act, section 1013, AHRQ is
working with other Federal agencies to create a program to
evaluate the comparative effectiveness of products and
procedures. The results of those evaluations will be made
available to the Medicare and Medicaid progress, as well as to
other Federal programs, such as the FEHB and the general
public. Our goal here is to organize the information so
consumers can get it in a timely manner and use it to make
informed decisions about their health care.
We are also exploring new technologies that allow consumers
to gain access to their personal health information securely
over the Internet, such as their medicine lists. Access to
trusted information like this on the Web, particularly if it is
delivered in a timely fashion, will revolutionize health care.
For providers, as you have pointed out, health IT offers
great intermediate potential to improve patient safety by
reducing medicine errors. The value, as you have noted, seems
obvious: reducing handwriting errors, cross-checking
prescribing errors, and identifying dangerous interactions
before they occur.
Health IT can also greatly improve the overall quality of
care by making the right thing to do the easy thing to do.
As a doctor, when I see a patient who is coughing and has a
fever I can now use an AHRQ-funded electronic tool to help
decide whether to hospitalize that patient. I used to have to
leave the exam room, go look up the information to make
treatment decisions. So it is an amazing innovation to have
that information available at your fingertips when it is
needed.
We have also taken health IT into settings where
traditionally it has not been available, including nursing
homes, pharmacies, waiting rooms, schools, and patients' homes.
The potential for cost savings from systematic use of
health IT results from removing inefficiencies, improving
physician decisionmaking, enhancing communication, and reducing
followup care due to medical errors, use of inappropriate
services.
A survey we fielded last fall found that approximately one-
third of patients reported that they have to go back for a
second visit because the relevant information was not available
with their clinician at the time of their first visit.
Our research has also demonstrated that computerized
reminders can reduce hospital charges per admission by
approximately 13 percent, and with your support we will
continue our efforts to provide sound evidence on the financial
benefits of health IT.
Mr. Chairman, I cannot overemphasize how important
practical technical assistance is to the successful adoption
and implementation of health IT, and to that end we have
created the AHRQ National Resource Center, the largest single
commitment to technical assistance that we have made in our
history.
This resource center leverages our investments in health IT
by offering help where it is needed in real-world clinical
settings that may be ill-equipped to meet the health IT
challenge. We do this by facilitating expert and peer-to-peer
collaborative learning and fostering the growth of online
communities that are planning, implementing, and researching
technology. As one of our grantees has told us, transition to
health IT is one part technical and two parts culture and work
process change.
This was designed initially to meet the needs of our
grantees, and we have recently opened this up to the Nation's
community health centers, and we will also be making it
available to providers working with the quality improvement
organizations.
So I would like to conclude by making a couple of brief
observations.
First is that health IT alone cannot provide the
improvements needed in our health care system. It has to be
integrated into individual clinical practices in an
interoperable system, as Dr. Brailer noted.
Second, for most health care settings, health IT is not yet
an out-of-the-box or, as Dr. Brailer said, a plug and play
solution. It is very important to remember that health IT
applications need to meet the needs of clinicians and patients
rather than the other way around.
A third important point is that the financial exposure for
providers, when added to concerns about doing it right,
increases the overall risk of making these investments. In
order to accelerate the pace of adoption and implementation, we
are committed to making sure that best practices and new
knowledge and experience are disseminated widely in order to
maximize the potential for quality improvement and reduce
economic risk.
We look forward to working with Secretary Leavitt, Dr.
Brailer, and our other partners to making health care for all
Americans better through health IT.
Thank you. I would be happy to take any questions.
Mr. Porter. Thank you, Doctor. We appreciate it.
[The prepared statement of Dr. Clancy follows:]
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Mr. Porter. I am concerned to a point where I felt today
was a critical hearing to start the process as my chairmanship
in this area. I think it is truly the future of health care in
America. But I am also concerned. Government does not always do
things very well. There are some things we do extremely well
and some things we do not do very well. But I believe, from a
health care perspective, we can do a lot of things right
because of some of the sizes of our employees, the quantity of
our employees, and the size of the market that we could use as
a term now to work with.
But I am concerned outside with the private sector because,
as you have mentioned, there are the small providers and there
are the mid-size and the large. But I have seen so many of the
small providers that are accustomed to doing things the way
they have always done things.
Let me talk about doctors for a second. I know there are a
lot of doctors in this room and some of my best friends are
doctors. They do not always make good business people. They
certainly are practicing medicine and their specialty and they
are independent and they certainly--the bulk are very, very
good and some of the best in the world. But I am concerned that
many of them are not going to be receptive to this change in
the way of doing business.
Again, from the Federal perspective I think there are a lot
of things that we can do. But in the private sector what can we
do to help especially the small--I would think that the smaller
providers might have a bigger challenge even than the larger
ones because of the cost and the change. What can we do from a
market-based approach to help give incentives to these
providers, the doctors, the health care professionals to get
them to step up to the plate? I truly believe this is the
future of health care. I guess I ask that of both of you.
Dr. Brailer. I think your concerns are accurately placed.
There are certainly many large providers today that have the
capital, the know-how, and the capacity to go through this very
long-term process of changing their businesses to be more
oriented around their customers, less error-prone, and more
efficient. One of the good things about health IT is we have
all those success stories, which began making, I think, this a
very real phenomenon. And we are leaving behind a large share
of providers, and it is not just capital, it is know-how or
human capital.
I think the question comes down to: how do we make sure
that they have the capacity to finance this and they have the
human capital to make it succeed, because it is ultimately not
about software, it is about changing the way their practices
operate.
Unfortunately, this is probably one case where physicians
are being good business people. It is not in their financial
interest to put these tools in place. They do not get paid for
better quality. They do not get paid for more efficiency. In
fact, when they are more efficient they have less revenue. So
for the standard physician the implementation of the electronic
health record is a losing proposition.
So we view this as a three-part equation. How do we
increase the benefits of the electronic health record by
allowing them to monetize better quality? I think the efforts
that CMS has underway in pay for performance that are being
followed and matched by various parts of the private sector are
very encouraging. And, by the way, most of those efforts have
up to 20 percent of their program aimed at health IT subsidies
through those efforts.
Second, how do we lower the cost of the technology? One of
the implications of interoperability is that prices become more
modular, products become more modular, and prices I think go
down. But beyond that, one of our initiatives is around
certification so you can compare two electronic health records
on their features and know if they are the same and then ask,
if they are the same, why does one cost more than the other.
Third is lowering the risk, and I think this is where the
human capital equation comes in. How do we make sure that these
practices are not just buying software but they are changing
the way decisions are made and communications occur and they
engage with their patients. The QIOs have done a lot with this,
the Health IT Resource Center from AHRQ has done a lot with
this. There is a burgeoning movement of regional projects,
local projects, where providers come together to be able to
help provide those resources through medical societies or
hospitals.
One thing that we can certainly do is to remove regulations
that prevent those kinds of collaborations between hospitals
and physicians around developing an integrated model of care
for their patients with health IT.
So there is a lot we can do, but I think the fundamentals
are moving in the right way and the question is how do we now
accelerate it and be able to make sure that it delivers the
kind of result not just for doctors but for consumers.
Dr. Clancy. Just to add to those points, with which I agree
completely, it is incredibly important because something like
60 percent of the Nation's physicians practice in groups of
five or less, so this is not a problem that can be ignored or
that we can envision will somehow mysteriously transition away.
Many of these small practices provide very high-quality
care. I would agree with David completely that I think
consistent demands for quality are likely to set the stage for
greater interest among physicians in small practices.
Recently there has been a collaboration that involves both
the public and private sectors to select and prioritize metrics
for reporting on quality and ambulatory care. Private sector
organizations are going to be writing these into their
contracts in 2006, and these are also the same metrics that CMS
will use, so that reduces the burden of reporting at the same
time that IT is ultimately going to make it easier for them to
do that, so I think that is going to be a powerful incentive,
in addition to the growing interest in pay for performance.
And I would echo what Dr. Brailer had to say about practice
strategies. It has been observed by some people that one of the
reasons that physicians have been slower to adopt, in addition
to the economic ones, is that there has not been a so-called
``killer application'' for them in private practice. Yesterday
I heard about one from a small practice. If you are a doctor
and you have a patient for whom you have to get authorization
for selective prescriptions this often involves a 10 to 12-
minute wait on the phone. It is a little bit hard to be seeing
another patient while you are waiting online here.
So a physician whose four-person practice has gone through
this transformation and is very excited about it told me that
their nurse quit last week and this nurse used to actually sit
on the phone, and he figured out a way to automate this using
their electronic health record system, and suddenly, all of his
partners were newly re-excited about this. I think that is
likely to happen, but I think all of the efforts that we are
talking about here to make it easier to shorten this transition
phase from moving from paper to electronic records is going to
make it easy for small practices.
Mr. Porter. I know the doctors, and I am fortunate my
doctor I have been seeing for 20 some years is small practice
and he has stayed ahead of the technology curve, but I just see
so many that are overloaded with paperwork, and the file
cabinet gestapo comes in if it is not locked properly, and
doctors were getting frustrated, and many of those that want to
change even are having a hard time paying their medical
liability costs and staffing and they are not encouraging young
folks or even those that are changing careers to get into the
profession. I see this domino thing happening in health care.
But two points. One, I look forward to continued
discussion. I hope we can sit down and have a round table
discussion some time that involves some give and take in the
future. But it seems to me in the medical liability end that is
the one thing that has brought doctors together across the
country, and especially in Nevada, or the cost of medical
liability insurance has brought doctors together. We have had a
serious crisis in Nevada where you will see a for rent sign on
OB/GYN offices throughout the State because they cannot afford
medical liability insurance. I know Nevada is not isolated. It
is happening all over the country. So we are looking at
liability caps and different ways to help the doctors.
But maybe something we could consider is finding some
incentives for the medical liability carriers to provide some
assistance to the medical doctors and providers that fall into
using this new technology. There is no question the numbers
show that there is life savings and far fewer risk involved
with technology, so maybe that is something we can talk about
at some point, incentive for insurance carriers, because I know
they are having trouble even staying in business.
But the other thing I touched upon earlier, as a group of
Federal employees we have an opportunity to change culture
across this country because of the massive size of the group,
and I would think some of the things that you are working on
and that we are working on to put in place for Federal
employees will help create a new culture because of just the
pure size of our group. And we touch most every major insurance
carrier across the country and we touch families and doctors in
most communities. So I look forward to working with you both as
we look at both of those avenues.
I know we now have another Member with us. Any questions or
comments at this point?
Ms. Norton. Mr. Chairman, I want to apologize because this
is a hearing that I very much wanted to attend. In this last
week of Congress we seem to be chasing our tails, as I think
committees justifiably try to get in under the August wire but
are not leaving us all of the time to get where we must.
I just want to say one of the things we have to ask
ourselves is why what would appear to help save lives, correct
errors in a huge industry like this has been as slow as it has
been to do the IT conversion that others have been quicker to
move to. I am led time and again back to cost. Maybe this is
overly simplistic, but if it was all that much to it you would
have thought that the cost/benefit would have been done and the
results would have been in health care what you see in other
places.
The chairman mentioned one reason why, I think, and you add
on to that others. He talked about the cost, for example,
physicians, particularly in a city like this or any big city,
have with liability insurance. You talk about the out-of-
control cost of health care, period, outstripping inflation
year after year no matter what is done. There are huge
structural problems built into the way we deliver health care,
paying more for health care than anybody else and providing
less health care than any G8 or any advanced nation.
I think one of the concerns in the system that should be
the model, the FEHBP, will be for the average Federal worker or
Federal organization will be it is going to cost some money and
who is going to pay for it. The cost of doing what it seems to
me inevitably must be done anyway and could have been done far
more cost efficiently had it been done a little at a time
beginning some years ago, but the cost of doing it--and you
have to do it now just to keep up with everything that
practitioners and health care organizations, just to keep up
with--I mean, just to keep in touch with those people you are
going to have to do it, so the inevitability of it is clear.
But when it really gets down to it, you are going to find
thoughtful people in the Federal work force are asking who will
pay for this, who will they pass the cost on to. Insurance
companies? Well, anybody who has seen the rise even in what we
have flattered ourselves to believe is the most efficient of
the health care systems in the country will have to simply
snarl at that one.
So I think your major problem or the major problem of the
Federal Government is going to be how to accomplish this in a
way that does not result in what almost everybody thinks it
will--that the cost of premiums are going to go up, that when
the buck gets passed it finally gets down to the family who is
middle income, cannot afford the health care they have, happen
to be in the Federal work force, and now, on top of rising
premiums, have the cost of the transition, the transaction
cost, if you will, into the IT that is inevitable and now is
beginning to occur and beginning to pay for it.
Have you thought through the--and perhaps I missed
everything important because I am just getting here. Have you
thought through whether that is the basic problem in this
entire sector, and, if it is, how we might begin to get around
that obstacle?
Dr. Brailer. I appreciate your question, and certainly
right here in the District are some leaders in health
information technology who are showing how to do this, but all
report the same challenge you raise. It is quite expensive, and
every business person outside of health care that we explain
this to says essentially the same thing: it does not make
sense. IT makes the bottom line better for most organizations,
so why not do it? And then we explain how DRGs work and fee for
service payments and various discounts and all the other
pieces, and if they are still following at that point they
begin to realize that it is not a very clean slate.
A large health care system can work through that and
largely will make an investment in health IT for strategic
reasons, to be out where they can be in the future. But the
standard doctor's office, small doctor office, small hospital
faces significant challenges. And the challenges I think come
down to being able to have what the doctor does and how they
get paid be aligned with how they produce better care.
This is why I think some of the efforts in pay for
performance, to be able to pay for better health status that is
seen by patients, is something that also incents health IT
because it is hard to do those over the long term without
having the information tools in place, and it is hard to report
them and to demonstrate what you have done without having the
tools to document.
There are also a lot of ideas about how to lower the cost
of these technologies, and there are a variety of proposals in
this area, but the simplest and most accessible ones are
letting the physicians have better access to market forces, to
use their negotiating power and the tools that they can use to
get better tools for their demand.
There is one area where I think we are concerned about, and
that is for very small physician practices, between one and
five physicians, that they do not have the kinds of tools
available to them at a good price. This is the area where we
have targeted the Medicare's Vista Office DHR product, which is
a much lower-cost solution for those practices.
So I think there is a lot that can be done, but I think
your comments are directly in the spirit of thism it is a very
long-term change, and no matter how fast we go it is going to
be a series of hopefully radically incremental steps, but
certainly incremental steps in their own right.
Ms. Norton. Finally, let me say if your view is as mine is,
if anybody can afford to be the model it is the FEHBP, it is
the Federal Government, then the first thing you want to erase
from your vocabulary is the word ``radical.'' Government does
not operate in that way. And what it seems to me can be most
useful to us is for those of you--is this Mr. Clancy?
Dr. Brailer. It is Dr. Brailer.
Ms. Norton. Dr. Brailer, I am sorry. It is Dr. Clancy.
Those of you who have been thinking this through can, for a
moment, posit the real world in which we live. We do not live
in a world in which market forces determine health care. See?
You are all waiting for that. You are going to have to wait
perhaps longer than any transformation to IT occurs. There are
too many competing interests and views about health care.
The Federal Government has, in fact, led the way in doing a
lot of things, but it has never taken huge steps. We have been
willing to take steps using agencies, parts of agencies. We
have been willing to do pilots. So if you want to frame this
issue the way you did in answering my question about how we
have to let physicians have more access to market forces and we
have to understand that people, in order for people's insurance
to be based on the state of their health care, which lots of
younger people want, that you are going to have to have
information to the data.
If that is the way, if that is the futuristic way in which
you want to frame it, then I can guarantee you that the
incremental steps--and the words ``radical'' and
``incremental'' is very good for the private sector, does not
work over here.
The kinds of tough thinking we need is how to hook us up.
It might be through those parts of the health care system that
we have some control over. That is why I mentioned FEHBP. But
you could also mention parts of the Medicaid system, you could
mention parts of the Medicare system. You could take parts of
that system where you do not put democrats against republicans
by having coming out of your mouth ``market forces.''
If you are going to talk that way, you are going to get
people like me to say, what are you going to do about 43
percent of the people that do not have any health care? You are
going to get people like me to say, and I can give you another
40 percent who have it, cannot afford it, and are giving it up
every day.
You need to help us think through a way to move the health
care sector gradually here by having Uncle Sam, who is in the
best position to take a giant step, prove that it can work by
carving out so that we can see how to make it work, what works,
and what does not work, carving out some part of what we have
some control over and then going ahead to doing it.
So I am just asking you not to put all of your ideas on the
table in one point, because all you do is divide us then. You
have terrible, terrible divisions here on health care. If what
we are talking about is what brings us all together is what
Newt and Hillary are talking about, that IT'ing all of this can
help save lives and even ultimately reduce cost, then you have
a huge laboratory over here.
Find parts of it, recommend to the chairman an agency, part
of the health care systems that we operate for Medicare to
Medicaid to FEHBP. I would be most open to working with the
chairman and to any others who are interested in bringing the
Federal Government as a pathbreaker into IT, saving lives and
saving money.
Dr. Brailer. Thank you. Congresswoman Holmes Norton is my
Congresswoman and the point is well taken. Thank you. I look
forward to working with you.
Ms. Norton. Obviously he lives in D.C. and he knows he had
better not cross me. [Laughter.]
Mr. Porter. Again, we thank you and we will conclude this
portion.
Dr. Clancy, Dr. Brailer, we appreciate it. I have another
hundred questions, but I will save those for some other time. I
look forward to working with you in the future.
Thank you.
Our fourth panel, we will hear from Dr. Harvey Fineburg,
president of the Institute of Medicine; David St. Clair,
founder and CEO of MEDecision, Inc., and Jan Walker, the
executive director for the Center for Information Technology
Leadership.
Welcome. We appreciate your being here today. If you would,
keep your comments to about 5 minutes.
We will start with Dr. Fineburg. Thank you for being here.
STATEMENTS OF HARVEY FINEBURG, M.D., PH.D., PRESIDENT,
INSTITUTE OF MEDICINE; DAVID ST. CLAIR, FOUNDER AND CEO,
MEDECISION, INC.; AND JAN WALKER, RN, MBA, EXECUTIVE DIRECTOR,
CENTER FOR INFORMATION TECHNOLOGY LEADERSHIP [CITL]
STATEMENT OF HARVEY FINEBURG
Dr. Fineburg. Good afternoon. It is a pleasure for me to be
here. I am delighted to be here this afternoon, Mr. Chairman. I
thank you for the privilege of testifying before the committee
today.
You have a very important subject that you are tackling,
and I would like to just offer a few observations orally. I
have submitted my written testimony to the committee.
The first point I would like to make, Mr. Chairman, is to
reiterate a point that came up earlier, that when we are
talking here about the quality of health care and the safety of
individuals, information technology is a tool, but it is a tool
that has to be embedded in a complete system dedicated to
higher quality and greater safety of care.
Rather than thinking about devising a training program that
can prepare physicians and other health professionals who are
capable of delivering high quality care that is safe, doing the
right thing, we ought to be designing systems of care that are
incapable of doing the wrong thing. If you want a fail safe
health care system, information at the time you need it that is
accurate and relevant to the decisions that are being taken is
an essential part of that puzzle.
So information technology in its own right has a great deal
to contribute to making the system a safer and a high quality
system.
The second point that I would like to suggest is that, as
you look at the opportunities for the Federal Employees Health
Benefits Program, both for the welfare of those employees who
are entrusted to this committee and also as a model for the
Nation, there are many opportunities, I believe, that you can
extend on the important initiatives that were described earlier
today by Director Springer and others.
For example, the FEHBP can make a commitment to recognize
only certified IT products at the time national certification
comes online. It can hasten, in other words, the adoption and
reliance upon products that meet common standards.
Second, the FEHBP can do more to insist upon the collection
and reporting of quality measures using data that is
electronically available and demonstrate improved performance
for the members of FEHBP. It can do this in a way that also
utilizes pay for performance that depend upon the success of
interventions to meet standards of quality.
The health informatics available through the FEHBP can be
applied to deliver the best quality care for the patients in
the program, regardless of whether they are in acute care
hospitals, in chronic care facilities, in ambulatory settings.
It can encourage those data systems that can also be used to
reduce the likelihood and to increase the detection of fraud
and abuse in the system. And the particular advantage that is
has, Mr. Chairman, is that the FEHBP, while a Federal program
for Federal employees, is embedded nationwide in the private
sector and the private insurance system, and therefore it is a
perfect case in point where initiatives of this type can
encourage and can hasten the adoption of appropriate
information technology.
I would like to conclude by saying that it will take more
than information technology to accomplish what information
technology, itself, is aimed to accomplish: the high quality
care. It will take change on the part of those physician
practices and the payers of care, as well as those who are
involved in the service and support functions. But there is a
great deal of ingenuity and willingness in the community all
over this country, and putting the incentives in the right way
through FEHBP I believe will encourage the right decisions at
the right time for all of our patients.
Thank you very much, Mr. Chairman.
[The prepared statement of Dr. Fineburg follows:]
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Mr. Porter. Thank you.
Mr. St. Clair.
STATEMENT OF DAVID ST. CLAIR
Mr. St. Clair. Thank you, Mr. Chairman. Thank you for
having me here.
I guess I would like to start by echoing something that Dr.
Brailer said. As the CEO of a technology company, I would like
to simply state that I agree with his assessment that this is
not about technology. This really is ultimately about improving
the quality of care and managing the cost of care so that it
can be available to more and more of our citizens in the coming
years.
Having said that, a lot of the advances that we can make
are, in fact, based in technology, but those are a means to an
end, not the end, itself.
One of the things that I think is important--my testimony
has been submitted in writing and I am going to just sort of
make a half dozen points--conversations about the electronic
health record, the EHR, are not synonymous with talk about
electronic medical records systems. The EMR, the information
that is available in hospitals and doctors' offices is not the
totality of the EHR.
Frankly, discussions as to how and when we should start
getting value from clinical data in terms of clinical
decisionmaking at the point of care should be separated as
quickly as possible from discussions about how to explicitly
expand the use of EMRs, per se, because I believe in the near
term--in fact, in production today--are systems that can take
clinical data and deliver them to the point of care to improve
patient care, to improve the quality of care, and reduce cost
without the presence of EMRs, without the presence of high-cost
technology in the doctor's office.
We are, for instance, today in production with systems that
take paid claims data and care management data and pharmacy
data and lab data that are available to the large regional
payers, highly processing that information into what we call a
patient clinical summary, which looks remarkably like an
electronic health record and, in fact, I would argue is the
most complete picture of a patient's health available today.
We are able to deliver that over the Internet in printable
form to a physician's office, and we are today delivering it to
emergency rooms in the State of Delaware to allow physicians to
get a more complete picture of their patient's history than
would otherwise be available to them.
This particular approach we believe is particularly
important for the FEHBP because of the fact that it is a step
that you can take essentially immediately to start getting the
health care system accustomed to using new sources of
information, new sources of data in the treatment of their
patients, and it does not require anything more than an
Internet connection and a printer in any particular physician's
office.
Furthermore, I think that it is important for us to
recognize that the infrastructure for any national health
information system is going to be paid for ultimately by us
being able to take better care of the 10 percent of the
population that is the sickest, that is consuming 80 percent of
the resources.
It is by achieving some substantial return on investment
with that particular population by improving their quality of
care, by reducing the amount of duplicative care in their
lives, that we are going to afford to pay for the
infrastructure that will support transactions for those of us
who are fortunately far less sick.
So there are strategies that are at work today in this
country that allow those folks who essentially are responsible
for the payment of care to get healthy returns on their
investment in systems that start to disseminate information to
the point of care with very, very little expense on the
provider side. Those tend to work through emergency
departments, through the sickest of the case and disease
management patients, but there are strategies that are being
employed today in the State of Delaware and in other States
that essentially follow that model.
The good news is that those strategies are not in any way
inconsistent with Dr. Brailer's strategy for the national
health information network. In fact, the availability of those
data sets early on in the process will help drive adoption of
the peer-to-peer networks and the regional health information
networks he wants to see by giving early users of those
networks access to data from the first day.
Ultimately, we think that we can help share the benefits of
HIT across the breadth of the population without waiting for
universal adoption of EMRs and other technologies in the
provider setting. I believe that technology needs to be
available for an extended period of time, because there is
going to be some period of delay between the adoption of EMRs
by, in effect, the richest provider groups, and it will slowly
then be adopted in the others. We need to have multiple ways of
delivering and gathering information from the provider setting.
Thank you very much.
[The prepared statement of Mr. St. Clair follows:]
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Mr. Porter. Thank you, Mr. St. Clair.
Dr. Walker, welcome.
STATEMENT OF JAN WALKER
Ms. Walker. Thank you and good afternoon.
I am a nurse from Boston with a longstanding interest in
understanding patients' experiences with our health care
system. I am currently executive director of the Center for IT
Leadership, which is a leadership group at Partners Health Care
System, and I am a member of the Health Information and
Management System Society [HIMSS]. You invited me today to
provide my views on how the Federal Government can use its
buying power to influence the use of technology in health care.
I brought a written statement to include in the record, and
I would like to make just a few remarks.
Professionally, I believe that information technology will
transform care in this country. But I am also a nurse and a
private citizen with a family and I would like to tell a
personal story.
A few months ago my nephew was diagnosed with thyroid
cancer. He lives in a small town in Kansas and goes to a State
university about 300 miles away. He needed surgery and he was
referred to a surgeon in a neighboring city. His parents called
me for advice. Should they send their son to this surgeon?
Of course, I wanted to know how many of these types of
cases the surgeon had done and how his patients had fared. To
paraphrase Dr. Clancy, I wanted to make an evidence-based
decision. But I could find no information to answer any of
these questions, and in the end we decided to bring my nephew
to Boston where I could depend on my local contacts to find the
most experienced doctors.
It sounds simple enough, but it required a barrage of phone
calls, signatures, and faxes to get information from his Kansas
workup. Scans were mailed to the wrong place and had to be sent
again. Results from several lab tests never did arrive and had
to be redone. A Boston pharmacist could not fill a prescription
because he could not reach the Kansas pharmacist by phone until
the next day.
Our studies at the Center for IT Leadership have analyzed
how information technology would address inefficiencies like
these, transforming the cost as well as the delivery of care.
As an example, we found that if all clinics and
laboratories ordered and reported lab tests electronically in a
standardized way, we could avoid $4 billion in unnecessary,
redundant tests, and $27 billion in paper handling and phone
costs every year.
If every clinic in the country adopted computerized order
entry with advanced decision support, we could save $44 billion
and avoid 136,000 life-threatening, adverse drug events every
year.
If the main stakeholders in patient care, doctors and
hospitals, labs and radiology centers, pharmacies, public
health departments, and payers, all adopted systems that
allowed them to exchange electronic information in a
standardized way, we could save $77.8 billion every year.
I will close with three thoughts. First, as we have seen in
multiple studies, the return on investment from HIT is
overwhelmingly positive. It has the potential to save billions
of dollars and dramatically improve the quality of care for all
Americans.
Second, HIT costs money. We must prime the pump by giving
providers incentives to invest. The costs of HIT are a huge
barrier to adoption, especially for small offices and small
hospitals. A combination of low-interest loans, tax credits,
and rewards for using HIT could help providers make this
transition.
Third, none of this can happen without national standards
that allow computers to talk to each other. Most of the dollars
we spend on systems that do not adhere to such standards will
go down the drain. If the Federal Government can use its buying
power to support standards development and implementation, to
facilitate availability of capital for providers, and to reward
providers who use HIT, we will move closer to transforming
care.
This week my nephew returned home to Kansas. I am crossing
my fingers that his Kansas doctors will hear from his Boston
doctors. In the end, these inconveniences did not compromise
his care, and I would even say they were relatively minor
glitches. Many patients are less fortunate. We feel very lucky.
On behalf of HIMSS, I thank you for this opportunity to
speak with you today. Both HIMSS and the Center for IT
Leadership stand prepared to help you in any way we can.
Thank you.
[The prepared statement of Ms. Walker follows:]
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Mr. Porter. Thank you very much, Dr. Walker.
I would like to ask all three of you a question. I think it
will help jump start as this committee moves forward.
Right now there are a lot of ideas, a lot of suggestions,
but we keep coming back to having to have what I believe is a
plan, a strategy, and certainly an outcome, and that is to
provide the best health care in the world and to make sure that
single mom or that dad or that senior, no matter their income
level, they have the best in the world.
What would you suggest, or how would you suggest we start
this cultural change? I know that we are really limited on time
and we are going to have additional meetings, but today what
would your message be to this Congress as we try to move
forward rapidly but also thoughtfully in this process of
changing our culture in the Federal Government? What would you
suggest, Dr. Fineburg?
Dr. Fineburg. Mr. Chairman, there are many ways to begin.
In fact, I think that the first one I would say is that there
is not a single magic bullet to transform health care in the
United States, so that we should not strive to solve the whole
thing with one fell swoop. But I would say that there are
significant opportunities that you have before you with the
tool that you are responsible for--namely, the Federal
Employees Health Benefits Program--to improve care for those
beneficiaries and thereby demonstrate what can be done.
For example, if Director Springer were to be the first to
adopt and insist upon the kind of certification standards that
virtually every witness has testified to, that would be an
enormous message of the importance of high-quality care across
the whole country.
Second, looking at ways to align the reimbursement and
payment systems with the kind of behavior that we are seeking
on the parts of patients as well as our care system, to
eliminate the advantages of doing the wrong thing by having
more resources given to you, and instead reverse that so that
you are reimbursed for doing the right thing and having
patients better off, that is, I think, a very important
opportunity which comes out of this pay for performance set of
strategies.
And, by the way, no one is absolutely clear what the best
way to do that is, so having in mind that you are going to try
different ways and learn from the experience I think would be a
wonderful frame of mind for the FEHBP, because that would
suggest that you are acting and also committed to improving
over time.
Those are two things I would suggest. You have turned to
others.
Mr. Porter. Mr. St. Clair.
Mr. St. Clair. While I would agree that there are many,
many places to start, I guess that I would also like to caution
that there are many places not to start. There is the common
statement these days about boiling the ocean. We cannot try to
solve every problem all at the same time, which is why I think
it is useful to try to break the problem down into its
component parts.
I believe that a place to start is with technology that is
available today broadly across the market to take data that
already exists in electronic form and begin to share it now.
What we want to do to start is start. There is information that
is available that is tremendously valuable in different
settings, like emergency rooms and things of that nature, that
we could start doing quite literally tomorrow because it is
being done today, but to do it more broadly.
And the FEHBP, it is a redundant program, is a tremendous
opportunity because you can influence that sort of pilot
process across dozens and dozens of health plans all over the
country by getting them to essentially involve your members
within theirs, and that is essentially going to start drawing
in their own participation in that same program. I happen to
like that as one of the places to start.
But, to your point, without pay for performance you are
going to start and you are going to start to slow down because
you are going to start getting resistance from the provider
sector once you get past the early adopters and their side. So
there really are those two avenues that I would say to move
down.
Mr. Porter. Dr. Walker.
Ms. Walker. I certainly agree with those points. I guess in
a sense we have already started, and there are a lot of success
stories out there. I think it will help to publicize the
success stories. Providers became providers because they want
to provide good care. They are humanitarians at heart. They are
really busy, and sometimes I think they do not have time to see
the possibilities of HIT, and I believe publicizing some of the
good work that has already happened might help them get over
that conceptual hump, which we need to accomplish.
Mr. Porter. Very good. As we have mentioned throughout the
hearing today, we still have the best system in the world, some
of the best doctors. And yes, we really need to recognize those
that are being successful.
Mr. St. Clair, I concur. There are some things we can do
right away. My kids, our kids, we have a lot of folks that
understand technology far better than I do, and there are young
folks, senior folks that could get up to speed really quick on
some of the things that you are suggesting as far as the
patients and understanding. And I agree with what you are
saying by separating these areas. I think that is important.
Mr. Fineburg, I concur wholly with you that the steps have
to be taken as soon as possible, but what I am going to suggest
is that we are going to move forward. I think we, as a Federal
Government delivery system, we have some of the most advanced
technologically businesses in the world that are providing
health care insurance to our employees. They are the most
sophisticated when it comes to investment, they are
sophisticated in delivery, they are sophisticated in the
product that they provide because they have been forced to by a
market that is demanding better and better service.
I have no doubt that we can take some of your ideas, and I
hope that you will join me as we compile some possible
legislation. But I think we have the best and the brightest, of
course, in the health care field, but also in the business
community. If we can provide some incentives that will force
some changes in a culture, I think we can help expedite in
technology.
And I say this because I used to work for an insurance
company for 20 years. It is not in the health care. It is
property and casualty company. But I know that it is one of the
largest in the country. We had to make changes because the
market demanded it, and to be competitive and to provide the
best property and casualty insurance we had to do it. We were
stuck with having one of the best computer systems in the
1970's in the world, and then we threw bandaids on it through
the 1980's, and all of the sudden we were so far behind the
curve we were forced to make some major changes.
I think that the Federal employees, as being the largest
customer base in the world, probably, we can provide some
incentives to make sure that the best and the brightest in our
partners, the carriers, can help work with the doctors and our
employees, which will set the standard and create a whole new
culture for the country.
So, having said all that, we are going to have to conclude
the hearing. I want to thank you all very much for being here.
I am very excited to be a part of this and plan on being very
active and look forward to working with all of you. Thank you
all for being here today. I appreciate it.
[Whereupon, at 4:15 p.m., the subcommittee was adjourned.]
[The prepared statement of Hon. Elijah E. Cummings
follows:]
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